Doctors who are constantly tired risk their own health and that of their patients. The BMA is pressuring employers to address the causes of sleep deprivation. Tim Tonkin reports
‘When I was a foundation year 1 and F2 I remember having to drive home exhausted was quite a common thing,’ says Daisy Yates, a junior doctor.
‘I remember driving and my eyes starting to go and having to open the window [to wake myself up].
‘If you’ve done a 12-hour shift, then an hour’s drive to get home, you will have been awake for a large amount of time.’
Dr Yates, now a specialty trainee 5 in old-age psychiatry, is recalling the dangerous levels of fatigue she often felt during a previous commute.
‘Once you go home you obviously have your sleep, but by working nights you are changing your whole [sleep] cycle,’ she says.
‘You’ve also got to consider that working on call is often busier than a normal day shift.’
Tackling workplace fatigue resulting from sleep deprivation has been one of the BMA’s objectives during 2018.
A paper on sleep deprivation and the effect of different working patterns on doctors was published in January, revealing the startling negative effects that fatigue can have on a doctor’s health and professional performance.
It found that the effects of shift working were a ‘substantial risk factor’ for fatigue, with doctors among the most at risk owing to the often irregular and antisocial hours of their work.
Following up on this paper, the BMA produced a fatigue and facilities charter to address the mounting effects of sleep deprivation, fatigue and burnout on members of a profession who are having to staff an increasingly under-resourced and over-pressured NHS.
At its core, the charter attempts to support employers in upholding good practice, through a set of clearly defined actions.
It stresses the importance of good rota design, effective induction and training to help prepare staff unused to working nights, and to minimise the effects of fatigue resulting from working on call.
It says mess, catering and rest areas should be provided to on-call staff and that the facilities of these areas should adhere to a basic standard, such as a bed, towels, clean sheets, telephone and power sockets.
‘Having access to a room for the duration makes a real difference’
The charter also calls for employers to ensure there is reserved parking for staff working on call and, when providing rest facilities is not possible, that taxis and alternative travel services be provided to staff at the end of their shift.
Since its introduction in March this year, uptake has been encouraging.
Data gathered by the BMA has found that 88 per cent of relevant English trusts have adopted the charter in principle, and 17 per cent in full.
In line with recommendations made in the charter, 82 per cent of trusts offer inductions and training to staff new to working on call, 78 per cent have rest facilities for on-call doctors, while 81 per cent have travel arrangements such as a taxi service to get tired doctors home at the end of a night shift.
No minor problem
Despite these successes there are areas where improvements are still needed.
While 74 per cent of trusts provide mess or common-room facilities for on-call staff, 24 per cent do not and only 2 per cent have an action plan in place to rectify this.
Meanwhile, 74 per cent have redesigned rotas to minimise fatigue, though 21 per cent have not and 5 per cent have plans to change this.
The trusts with no immediate plans to make changes to promote doctors’ health and patient safety may be in a minority, but they collectively employ thousands of staff.
Dr Yates, who is based at London Road Community Hospital in Derby, says that while the trust signed up to the charter at one of the most recent local negotiating committee meetings, many aspects set out by the charter are already in place.
‘The good thing about our trust is that [for those on call] there are two bedrooms, an area to sit, a TV, a fridge and an area to make food.
‘I know somebody who when they did a weekend on-call, they were able to stay on site the whole weekend.
‘If you’re in the position where you are too exhausted to get home again between on-call shifts, having access to a room for the duration makes a real difference.
‘Studies consistently highlight the severity fatigue poses to the medical workforce’
‘The sleep charters are a very important issue, especially in trying to reduce levels of burnout and improving general well-being among doctors.’
Hampshire paediatrics ST1 Cristina Costache says that the introduction of the charter, while still a work in progress, has been an important step in the fight to tackle fatigue and sleep deprivation in the workplace.
She says fatigue, and working while tired, are often ‘hidden subjects’ among members of the medical profession, with doctors not wanting to admit or discuss when they’ve been pushed beyond their physical limits.
‘People don’t like to talk about their weaknesses. It is very difficult as a doctor to accept the fact that you have reached your limit because we’re all perfectionists, and it’s the most frustrating thing to realise you’ve reached your limit.
‘It makes you worry [when you’re that tired] because you realise that there are very few doctors covering the hospital at night. It makes you worry because on the one hand you have responsibility for the safety of your patient and secondly, responsibility for your own safety.
‘It affects the way you feel as a doctor and not being able to meet the potential that you’re expected to, because of being tired.’
Wall of sleep
Dr Costache says that, while many doctors are able to manage their fatigue levels for short periods of time, an accumulation of tiredness can eventually get the better of even the hardiest individuals.
Efforts to tackle causes of sleep deprivation and fatigue and improve working standards for doctors working on call are not limited just to England.
BMA Wales is also undertaking efforts to introduce a sleep and facilities charter, with negotiation with the Welsh Assembly and NHS Confederation under way.
As with its English counterpart, the Welsh charter will recognise the need for a universal standard in doctors’ facilities, with a focus on rota design and guidance to employers on better practice for addressing sleep deprivation and fatigue.
BMA junior doctors committee chair Jeeves Wijesuriya says the BMA charter is one of the most important pieces of work produced by the BMA and welcomes the extent to which trusts across England have so far engaged with it.
He says: ‘The fatigue and facilities charter has been one of the most important pieces of work the association has produced in recent years.
'Studies, by the BMA and independent bodies, have consistently highlighted the scale and severity that fatigue poses to the medical workforce.’
BMA junior doctors committee deputy chair Peter Campbell adds: ‘It is positive that so many trusts are working to adopt the terms of the charter and taking steps to improve conditions either through upgrading facilities or appropriately modifying rotas.
‘We will continue to support doctors locally to ensure that they are able to access the high-quality facilities they deserve, promoting good practice and highlighting where facilities are not up to scratch.’
Find out more about the charter
Core elements of the BMA’s charter
Rostering and rota design
Rotas should be designed with no more than four long shifts in a row, a maximum of seven consecutive shifts and no more than 72 hours in a 168-hour period.
Induction and training
Trusts should ensure that a basic education on sleep and working nights is provided to staff during their initial induction.
Common room or ‘mess’
An easily accessible mess facility with appropriate rest areas, should be available to staff 24 hours a day, seven days a week.
The charter states that staff should have access to some form of catering facility 365 days a year, with facilities, such as microwaves, available in instances where the canteen is closed.
Employers should provide sufficient parking for staff and alternative travel arrangements for doctors who are too tired to drive home following a shift.
Rest facilities for doctors working on-call
Trusts should ensure there are sleep facilities, meeting defined minimum standards, available free of charge for all staff who are rostered or voluntarily resident on-call at night.
‘Nirvana’ – a good on-call room
My on-call room – all hospitals should have a good on-call room, it makes all the difference. #FightFatigue #YouMatter
Carpet? blinds? sheets?! What is this, nirvana? @ncl_medic
Is that... an ironing board and iron?
PC connected to intranet for results and imaging? Surely not? Fridge either broken or full of mouldy food.
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